1.2.40.0.34.6.0.11.2.171

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1 Template DiagnosticConclusionSection

The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.

1.1 Aktuelle Version

Id	1.2.40.0.34.6.0.11.2.171	Gültigkeit ab	2026‑07‑17 12:33:29
Status	Entwurf	Versions-Label	2.0
Name	DiagnosticConclusionSection	Bezeichnung	Diagnostic Conclusion Section
Beschreibung The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.
Kontext	Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.171
Label	atpatho_section_DiagnosticConclusionSection
Klassifikation	CDA Section level template
Offen/Geschlossen	Geschlossen (nur definierte Elemente sind erlaubt)
Benutzt	Benutzt 2 Templates Benutzt als Name Version 1.2.40.0.34.6.0.11.3.195 Containment Update Information Organizer (2.0) DYNAMIC 1.2.40.0.34.6.0.11.3.194 Containment Problem Organizer (1.0.0) DYNAMIC
Beziehung	Spezialisierung: Template 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (2014‑05‑13 19:31:26) ref psr- Spezialisierung: Template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07) ref ad1bbr-
Beispiel	example from use case #1 <section classCode="DOCSECT">   <templateId root="1.3.6.1.4.1.19376.1.8.1.2.5"/>  <code code="22637-3" displayName="Pathology report final diagnosis" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>DIAGNOSTIC CONCLUSION SECTION</title>  <text>     <paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</paragraph>     INVASIVE ADENOCARCINOMA OF THE BREAST.    <br/>     HISTOLOGIC TYPE: DUCTAL.    <br/>     NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.     <list>       <item>TUBULE FORMATION SCORE: 2.</item>      <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>      <item>MITOTIC RATE SCORE: 1.</item>    </list>     ICD-O-CLASSIFICATION: C50.3 M8500/31    <br/>     IN-SITU CARCINOMA: EQUIVOCAL.    <br/>     BREAST CANCER BIOMARKER STUDIES:     <list>       <item>PARAFFIN BLOCK NUMBER: A1.</item>      <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Percentage stained tumor cells = 85%, Allred Staining Score = 3).</item>      <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).</item>      <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</item>      <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.</item>      <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>    </list>  </text>  <!-- Start Level 3 for Diagnostic Conclusion-->   <entry>     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) 1..* R-->   </entry>  <entry>     <!-- template 1.3.6.1.4.1.19376.1.3.10.4.5 'Update Information Organizer' (2017-11-14T15:22:14) 0..1 R -->   </entry></section>
Item DT Kard Konf Beschreibung Label hl7:section 1 … 1 M atpa...tion @classCode cs 1 … 1 F DOCSECT @moodCode cs 1 … 1 F EVN   Constraint This section SHALL contain a code element populated with these attributes: @code ="22637-3" @codeSystem ="2.16.840.1.113883.6.1" @displayName ="Pathology report diagnosis"  This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader. The section SHALL contain as many Problem Organizer entry elements as there are problems or groups thereof investigated. Each entry provides machine-readable data. This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document. hl7:templateId II 1 … 1 M atpa...tion @root uid 1 … 1 F 1.2.40.0.34.6.0.11.2.171 hl7:code CE 1 … 1 M atpa...tion @displayName st 0 … 1   @codeSystemName st 0 … 1 F LOINC @code CONF 1 … 1 F 22637-3 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC) hl7:title ST 1 … 1 M atpa...tion   CONF Elementinhalt MUSS "Ergebnis" sein hl7:text SD.TEXT 1 … 1 M atpa...tion   Beispiel example for use case#1 <text>   <paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY) </paragraph>   INVASIVE ADENOCARCINOMA OF THE BREAST.  <br/>   HISTOLOGIC TYPE: DUCTAL.  <br/>   NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.   <list>     <item>TUBULE FORMATION SCORE: 2.</item>    <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>    <item>MITOTIC RATE SCORE: 1.</item>  </list>   ICD-O-CLASSIFICATION: C50.3 M8500/31  <br/>   IN-SITU CARCINOMA: EQUIVOCAL.  <br/>  <br/>   BREAST CANCER BIOMARKER STUDIES:   <list>     <item>PARAFFIN BLOCK NUMBER: A1.</item>    <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Percentage stained tumor cells = 85%, Allred Staining Score = 3).</item>    <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).</item>    <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</item>    <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.</item>    <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>  </list></text> hl7:entry 0 … 1 C Source:  PaLM Suppl. APSR 2.0-3: 6.2.5.4 Beinhaltet 1.2.40.0.34.6.0.11.3.195 Update Information Organizer (DYNAMIC) atpa...tion @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true   Constraint if ClinicalDocument.versionNumber > 1 hl7:entry 1 … * M Source:  PaLM Suppl. APSR 2.0-3: 6.2.5.2 Beinhaltet 1.2.40.0.34.6.0.11.3.194 Problem Organizer (DYNAMIC) atpa...tion @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true

1.2 Zusammenstellung aller Versionen dieses Templates

• 2026-07-17 12:33:29 (In Entwicklung)